First 50 Robotic Knee Surgeries at San Francisco Surgery Center: Q&A With Orthopedic Surgeon Dr. Kevin Stone and Surgery Center Administrator Jeff Wong

One year ago, the San Francisco Surgery Center (SFSC) acquired the world's first MAKOplasty robots for partial joint replacements in an outpatient surgery center. Since then, surgeons at the SFSC have performed over 50 procedures using this technology.   Jeff Wong, SFSC's Administrator, and orthopedic surgeon, Kevin R. Stone MD, discuss the benefits and challenges of incorporating this technology into a surgery center and where they believe robotics is headed.

Q: What has been the key to your success with robotic joint replacements in the outpatient surgery center setting following these 50 MAKOplasty procedures?

Jeff Wong:
One of the keys to our success has been that our staff thoroughly understands the patient recovery and anesthesiology techniques that enable patients to recover from the procedure quickly and comfortably. I think that's one way an ASC excels from what a hospital can offer. We focus on getting patients up on their feet safely and comfortably within hours, rather than days after their procedure. Fortunately, it's been a very smooth process so far, and we have had zero transfers or revisions.

Another important factor in being able to take a traditional hospital-based procedure into the outpatient setting has been careful patient selection. We screen our patients to make sure they are suitable candidates for surgery in an ASC. If they have potentially risky comorbidities, we advise against them coming to an ASC and instead be treated at a hospital that is better equipped to address their potential complications.

Q: How did surgery center physicians and staff adapt to the new procedure and technology?


Dr. Kevin Stone: We started off slow, but with each successive case we performed, it became increasingly more efficient. We were able to spend successively less operating time per case as the surgical team become more experienced in the OR setup and use of the robot. The patient's recovery management has also become much more efficient. Every patient has been able to leave the surgery center within two to three hours.

Q: What challenges have you encountered over these past few months?


JW:
Raising sufficient capital to purchase the specialized robotic equipment was our greatest challenge. It is a fairly expensive piece of equipment. The other challenge was simply finding the physical space to store it since the robotic system is comprised of three separate, mobile stands. Other than that, gearing up for incorporating robotic joint replacements into the surgery center was relatively easy since MAKO was able to train our staff in a few hours.

Q: Has the procedure been profitable for the surgery center considering the high price of the technology?


JW: From a cash flow perspective, it is a profitable procedure. The key is getting adequate volume so that we can cover the monthly fixed costs of equipment ownership.   

Performing partial joint replacements as an outpatient procedure can also be more beneficial for insurance companies because ASC reimbursement rates are typically lower than the same cases performed at a hospital. Furthermore, we have eliminated the need for a multiple day hospital stays, which presents a considerable cost savings for insurance companies.

KS: From a cost of care perspective, using the robot helps address the rising costs of healthcare because it's much less expensive to perform a partial knee replacement as an outpatient procedure and avoid hospital and hospitalization charges. I think it's a dramatic improvement and I suspect many partial and total knee replacements will be appropriate to do as outpatient procedures in the future. Clinically, we have had 100 percent success rate thus far with the robotic approach for partial knee replacements.

I've also had extremely high patient satisfaction. I attribute a large part of this satisfaction to the efficiency and precision of having the robot as an assistant in the partial knee replacement. The robot makes me a more accurate surgeon.

Q: What is the benefit of using the robot in the outpatient surgery center?


KS:
The best part of the robot is that the accuracy exceeds what we have been able to do with the normal cutting guides. Since we do most of the surgery on the computer, the knee incision and exposure greatly decreased. The number one thing I say to the patient is that the robot is more accurate than I am. I have been doing partial knee replacements for 25 years and I never been more confident that I can install the components in optimal alignment.

Also, I'm able to test alignment, tension, and angular correction of the leg in the OR and see the outcome on the computer screen and make adjustments as needed. In the past, I was only able to run these tests after the patient left the OR and then unable to correct it. The ability to make adjustments during a case is a big advantage.

JW:
There is also the intangible benefit of outpatient procedures being safer and more cost effective because the outpatient centers typically have a higher productivity rate and a far lower infection rate. It also brings piece of mind to the patient because they are able to have their surgery done in a friendly, intimate environment where the nursing and support staff is specifically trained and experienced in these orthopedic procedures.

Q: What does the robot bring to the surgery center beyond the clinical benefits?


JW:
The robot has been an enabler. It allows us to broaden the scope of surgeons who can be trained and certified by MAKO to do partial knee replacements at our ASC. As a result, we have been able to attract sports medicine physicians who are now comfortable performing the MAKOplasty procedure and take on more joint replacement cases.

Q: Where do you see robotic technology in surgery centers headed in the future?


JW:
I definitely see a place for robotic technology becoming increasingly popular for orthopedic procedures in surgery centers. We've already seen the value the Da Vinci robot has brought to the OR and we envision gaining comparable benefits with the MAKO. While we have focused exclusively on partial knee replacements up till now, we anticipate leveraging the robot for hip replacements and possibly shoulder repairs in the near future.  There is definitely a role for robotics in the surgery center because just like the auto industry, robotic technology will help make our industry faster and more effective while also improving precision, balance and consistency. I envision MAKOplasty robotic procedure in orthopedics is somewhat comparable to the LASIK in ophthalmology.

KS:
As MAKOplasty increases in popularity with surgeons, it's very likely that partial knee replacements will be increasingly performed in ASCs and eventually transition to total knee replacements when that technology is in place. I also think insurance companies will push for more of these types of outpatient alternatives to reduce their costs. This approach is far cheaper, more efficient, and has consistently better outcomes.

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